Wellness

A Pain in the Wrist: Carpal Tunnel Syndrome

Four weeks into
nail school at Chris’s Beauty College in Gulfport, Miss., Selina Rodriguez began feeling pain in her left hand that worsened when she filed acrylic nails. “It felt like a sore bruise” says Rodriguez. “I’ve had minor aches in my hand before, but nothing that felt quite like that. I told my instructor about it, and she told me it was probably carpal tunnel syndrome. She too suffered from it and had to have surgery.”

Rodriguez’s predicament is not uncommon among nail techs. According to NAILS’ 2012-2013 Big Book, of the 40% of nail techs who report work-related health concerns, carpal tunnel syndrome (CTS) is the most common, at 42%. Among the general population, CTS affects approximately 10%, and while it’s an unusual occurrence in people younger than 20, it’s now presenting in that population more often as well. “We’re seeing CTS happening at very early ages,” says John T. Knight, M.D., director of the Hand and Wrist Institute in Beverly Hills. “The reason is automated technology — texting, computers, and gaming.” With all the repetitive motion (one of the causes of CTS) required by contemporary day-to-day life, how can CTS be prevented and/or treated? It helps to first understand exactly what CTS is.

WHAT IS CTS?

According to the National Institute of Neurological Disorders and Stroke, carpal tunnel syndrome is a result of compression of the median nerve — which runs from the forearm into the palm of the hand — at the wrist. The median nerve controls sensation to the palms, thumbs, and middle three fingers of the hands, and also controls impulses to small muscles that control movement. The median nerve and tendons are located inside the carpal tunnel, which is a narrow tunnel of ligament and bones at the base of the hand. Inflammation or thickening of the tendons can narrow the carpal tunnel and cause compression of the median nerve.

WHAT ARE THE SYMPTOMS OF CTS?

The result of this compression of the median nerve is often weakness, numbness, tingling, pain that radiates up the arm, and other symptoms. These symptoms usually start gradually with burning, tingling, itching and/or numbness often concentrated in the thumb and the index and middle fingers. Swelling or the sensation of swelling is also common. Because of the loss of feeling in the fingertips, some sufferers have trouble performing intricate tasks, such as fastening hooks or clasps on clothing and jewelry, and may even lose the ability to feel hot and cold temperatures. Symptoms can appear in both hands simultaneously or one hand may be more affected initially. Because many people sleep with their wrists flexed, symptoms may first appear at night, causing a person to awaken feeling the need to “shake out” the hand or wrist.

WHAT CAUSES CTS?

There are myriad factors — often a combination of them — that can cause pressure on the median nerve and tendons in the carpal tunnel. “There is often a hereditary predisposition,” says Dr. Knight. “The carpal tunnel can simply be smaller in some people. Other contributing factors include inflammatory conditions, such as rheumatoid arthritis; metabolic abnormalities, such as thyroid disease and diabetes; and trauma, such as fractures.” And while the National Institute of Neurological Disorders and Stroke reports that there is little clinical data to prove whether repetitive and forceful movements of the hand and wrist cause carpal tunnel syndrome, other related disorders such as bursitis and tendonitis have been associated with performing repetitive motions. Additionally, a recent case-control study of surgically-treated CTS found that reasonable evidence exists that regular, prolonged use of hand-held powered vibratory tools more than doubles the risk of CTS. This study is cited in an article by Keith T. Palmer, professor of occupational medicine and MRC clinical scientist. In the same article, Palmer reports that, “There is substantial evidence for similar or even higher risks from prolongedand highly repetitious flexion and extension of the wrist, especially when allied with a forceful grip.” The intricate work a nail tech does clipping, shaping, and filing — not to mention the vibration from e-files — would certainly constitute prolonged repetitive motion.

A chiropractor performs a nerve conduction study.

HOW IS CTS DIAGNOSED?

A physical examination can help to determine if the pain is being caused by an underlying disorder or if the pain is related to daily activities. It can also rule out other conditions that mimic carpal tunnel syndrome; lab tests, X-rays, and/or ultrasound can reveal diseases and injuries such as diabetes, arthritis, or fractures. Two tests to specifically pinpoint CTS may be employed. The first is the Tinel test, where the physician will put pressure on the median nerve in the wrist. If CTS is present, the patient will feel a tingling or a shock-like sensation. The second test, called the Phalen, or wrist-flexion test, will produce similar results within one minute if CTS is present. In this test, the patient points the fingers downward and presses the backs of the hands together.

Dr. Knight says that diagnosis is mainly based on the patient’s history and the physical examination, but that electrodiagnostic testing is important to determine the severity. This may involve a nerve conduction study, wherein small electric shocks are applied to the hand and wrist via electrodes to measure the speed of nerve impulses. A second electrodiagnostic test is electromyography. A fine needle is inserted into a muscle and the electrical activity is measured to determine how well the median nerve is functioning.

HOW IS CTS TREATED?

Conservative treatment for CTS, according to Dr. Knight, involves using a brace at night, rest, NSAIDs — such as aspirin, ibuprofen, and other nonprescription pain relievers — activity modification, and ergonomic modifications of the work station. “Prior to surgery,” says Dr. Knight, “a cortisone injection may provide some temporary relief.”

Non-surgical treatments

If you are postponing surgery, there are a few other options to try in addition to the above suggestions. Diuretics can decrease swelling and relieve pressure. Stretching and strengthening exercises, if not too painful, can be helpful (see sidebar for links to CTS stretches). Some CTS sufferers claim to have found some relief through alternative therapies such as acupuncture and chiropractic, and yoga has been shown to improve grip strength and alleviate pain.

Another alternative therapy for CTS, an external suction technique called cupping, has been shown to provide temporary relief. In a German study published in The Journal of Pain, researchers randomly divided 52 CPS patients into treatment and control groups. The treatment group had cupping glasses applied to their skin over the trapezius muscle — which creates a partial vacuum — followed by five to 10 skin punctures with a sterile lancet. Results showed that CTS patients given cupping treatment experienced reduced symptoms and pain and higher functionality for one week after treatment.

Surgery

One of the most common surgical procedures in the United States, carpal tunnel release is generally recommended if symptoms don’t abate with other therapies or if the symptoms last for six months. There are two types of surgery, endoscopic tunnel release and open release, which both involve severing the band of tissue around the wrist to reduce pressure on the median nerve.

“Endoscopic carpal tunnel release, which is the newest, cutting-edge treatment, is a 10-minute outpatient surgery performed under either a regional or general anesthetic,” explains Dr. Knight. “A lighted scope is placed into the carpal tunnel through a 1-cm incision. A knife is deployed to cut the ligament to relieve pressure on the nerve. The skin is glued together and a bandage applied. Surgery requires very few pain pills and likely only a few NSAIDS. A complete recovery usually occurs within weeks.” Endoscopic surgery may offer less postoperative pain and faster recovery than the traditional open release method.

HOW IS CTS PREVENTED?

As a nail tech, your days may be jam-packed with clients, leaving you little time to rest or take breaks, but not doing so can leave you vulnerable to CTS. Be sure to take the time to perform stretching exercises and do your best to take standing or walking breaks between clients. Use correct posture and wrist position, and make sure your workstations and tools are ergonomically efficient. If you begin to feel symptoms, wearing splints or braces can keep your wrists straight, and fingerless gloves can keep your hands warm and flexible.

The most important thing to do if you suspect CTS is to get a proper diagnosis; if left untreated it can cause permanent damage to the median nerve or cause the muscles at the base of the thumb to waste away. Surgery is sometimes the only viable option in order to continue a career in nails. “Right now, I’m just massaging my hand and stretching it and using less pressure in order to not feel pain,” says Rodriguez. “But it will definitely make it painful for me to do nails if I don’t find a solution. I plan on seeing a doctor as soon as possible, and I’d advise anyone with symptoms to get them checked out right away. Don’t let this be an obstacle if being a nail tech is what you love.”

VICKI PETERS: MY CTS STORY

Vicki Peters

About eight years into my nail career, my hands started to periodically go numb and I would have to lower them to my side and shake them to get the blood back into them. I also tend to sleep with my hands curled under my pillow, and I would wake up and my hands would be stiff. I remember as early as five years prior to doing nails, my hands were unusually stiff in cold weather, so I suspect I had the beginning stages of CTS then. I was lucky because I was not working in the salon at the time and knew I couldn’t return to nails full time until I had the surgery.

I saw a hand specialist and went through some tests to confirm what I already knew. They stick push pin-type needles that are attached to wires into the muscles of your hands. They send electricity through the wires and watch the movement in your hands to determine how severe the carpal tunnel is. My surgeon told me that because I also had numbness in the tips of my index fingers, I was beyond therapy and needed surgery. He also could not guarantee I would get the feeling back in my fingertips (which, thankfully, I did).

Both hands were equally affected, but I chose to have surgery on my left hand first because it seemed to bother me the most. My first surgery was in the early ‘90s, and the second was not until 2004. After each surgery, it was a few months before I spent any time at my nail table, only because I was afforded the time. It took the better part of a year before I felt I was 100% back to normal. Had I needed to go back to doing nails full time, I would have certainly had to wait six to eight weeks.

After the first surgery, I didn’t have therapy; it was not suggested and I wish it had been. Years later when I did my right hand, I did do therapy, which made the biggest difference in my recovery. It took me three months to feel like I felt after a year with the first one, so I highly recommend it. A few other suggestions:

Change up your station by making sure your clients are not holding the table down while you are working on them! The pressure they apply on your hands as you work on them can really hurt you in the long run. Make sure the client’s elbows are on the table; have an arm rest under her wrist so she relaxes her hands and does not apply pressure on your hands.

Sleep in braces made for CTS. They keep your wrist straight so you cannot curl your wrists. I slept in them for 20 years and still do when my hands hurt. I also would drive with them on for relief.

A great preventive stretch can be done by pressing the palms of your hands together so the tips of your fingers touch and the heels of your hands right above the wrist touch (sort of a prayer position). Now raise your elbows — you can feel the stretching in the wrist area.

Click here to see a video of Vicki Peters demonstrating a CTS exercise.

CTS Prevention Stretch

1. Place the palms together in prayer position. Keeping the heels of the hands together, slowly lower the hands and raise the elbows so the angle at the wrist decreases.

2. Push your fingers together and hold for 10 seconds. Repeat up to 10 times, multiple times a day.

Today, the Georgia governor lifted the stay-at-home restrictions, which means salons and barbershops are allowed to resume open hours. The Georgia State Board of Cosmetologists and Barbers issued these guidelines in light of the COVID-19 global pandemic.